Compositions and methods for treating galactosemia

ABSTRACT

The disclosure relates to methods for treating galactosemia and manifestations of galactosemia using aldose reductase inhibitors.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit to U.S. Provisional Application No.62/538,443, filed Jul. 28, 2017, which is incorporated herein byreference in its entirety.

BACKGROUND

Galactosemia is a metabolic disorder that results from reduced abilityor inability to metabolize galactose. The disease is typically caused bydeficiency of one or more enzymes involved in the Leloir pathway,including galactose-1-phosphate uridyl transferase (GALT), galactokinase(GALK), and galactose-6-phosphate epimerase (GALE). Deficiency of one ormore of these enzymes results in the disruption of the Leloir pathwayand accumulation of galactose and certain galactose metabolites, such asgalactose 1-phosphate (G1P) and galactonate. In addition, when galactoseaccumulates, it can become a substrate for aldose reductase (AR), anenzyme in the polyol pathway of glucose metabolism. AR normallycatalyzes the reduction of glucose to sorbitol (the first step in thepolyol pathway), but can also convert galactose to galactitol whengalactose levels are elevated. The accumulation of galactose andgalactose metabolites can cause damage to the liver, central nervoussystem (e.g., brain), kidneys, eyes, and other body systems (Quan-Ma etal., Am J Dis Child., 112(5):477-478, 1966).

Genetic disorders that cause galactosemia can be detected using suitablescreening tests (Berry et al. in “Classic Galactosemia and ClinicalVariant Galactosemia,” GeneReviews, Roberta A. Pagon, Eds. University ofWashington, Seattle; March, 2017). There currently is no cure forgalactosemia and the disease is managed principally through dietaryrestriction, by eliminating dairy foods and other foods that containgalactose or lactose from the diet. (Welling et al., “InternationalClinical Guideline for the Management of Classical Galactosemia:Diagnosis, Treatment, and Follow up,” J Inherit Metab Dis,40(2):171-176, 2017; Lai et al., IUBMB Life, 61(11):1063-74, 2009).However, even when galactosemia is detected early and managed via strictdietary restriction, galactose metabolite levels remain elevated and themajority of patients experience long-term complications such as speechdifficulties, cognitive impairment, neurological symptoms and ovarianfailure (Schadewaldt et al., Arch Physiol Biochem., 120(5):228-39, 2014;Berry et al., Mol Genet Metab., 81(1):22-30, 2004). However, even withstrict dietary control, galactosemia patients are still at high risk ofcomplications, due to endogenous (or internal) synthesis of galactosewithin the body. Endogenous galactose production has been shown to behighest in infancy and early childhood, but continues at a steady statethrough adolescence and adulthood. Endogenous production of galactoseresults in high levels of galactose metabolites in patients even withabsolute dietary compliance, and leads to incidence of long-termcomplications, including central nervous system complications(cognitive, intellectual, speech and motor deficiencies) as well ascataracts in the eye (which may result in partial blindness), andprimary ovarian insufficiency (POI) in galactosemic females.

The most common form of galactosemia, type I galactosemia (OMIM #230400)is caused by mutations in GALT, the second enzyme of the Leloir pathway.Mutations of GALK give rise to type II galactosemia (OMIM #230200). TypeIII galactosemia (OMIM #230350) is caused by mutations in GALE. Allthree types are autosomal recessive disorders. Based on the degree offunctional impairment of the enzymes (biochemical phenotype), genotype,and potential to develop acute and long-term complications, furthersubtypes of galactosemias have been identified.

The underlying mechanisms of galactosemia pathology are not fullyunderstood, but endogenous production of galactose, and resultingmetabolites, is considered to be a significant factor. (Welling et al.,J Inherit Metab Dis, 40(2): 171-176, 2017). Currently, the only therapyfor galactosemia is dietary restriction of galactose, and a life-longgalactose-restricted diet is the current standard of care. Although thediet can reverse the acute clinical picture in the newborn, it does notprevent the appearance of long-term complications. No mode of treatmentor prevention of any one of the long-term complications exists.

Accordingly, there is a recognized but unmet need for methods for thetreatment and/or management of galactosemia.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a graph showing weight gain of wild type rat pups (GALT+),GALT null rat pups, and GALT null rat pups treated with aldose reductaseinhibitor (ARI) (Compound A), Weight (g) is plotted on the vertical axisand age (days) is plotted on the horizontal axis.

FIGS. 2A-2D are charts showing the effect of aldose reductase inhibitorson cataracts in galactosemic rats. FIG. 2A shows the results of aqualitative assessment of cataract at day 9 presence/severity score(scale of 0-3) in control (wild-type rats treated with Compound A), andGALT-null rats treated with placebo or Compound A. Score 0 indicates nocataracts present; score 1 indicates cataracts are mild in size andopacity; score 2 indicates cataracts are moderate in size and opacity;and score 3 indicates cataracts are severe in size and opacity.Cataracts were assessed at day 22 of life. FIG. 2B shows the results ofa quantitative digital assessment of cataracts in wild type or GALT nullrats treated with Compound B or placebo at day 22 of life. FIG. 2C showsthe results of a qualitative assessment of cataracts in wild type orGALT null rats treated with Compound B or placebo at day 10 of life.FIG. 2D shows a qualitative assessment of cataracts in wild type or GALTnull rats treated with Compound B or placebo at day 22 of life. Thequalitative analysis in FIG. 2C and FIG. 2D was performed using the samescoring method as in FIG. 2A.

FIG. 3A-3C are bar charts showing the levels of the metabolitesgalactitol, galactose, and galactose 1 phosphate in liver, brain orplasma of control (wild-type rats) and GALT-null rats treated withplacebo or Compound B. FIG. 3A shows galactitol levels; FIG. 3B showsgalactose levels; and FIG. 3C shows galactose-1-phosphate (Gal1P)levels.

SUMMARY

This disclosure relates to methods for treating galactosemia andtreating or preventing complications of galactosemia by administering antherapeutically effective amount of an AR inhibitor to a subject in needthereof. Without wishing to be bound by any particular theory, and asdescribed herein, it is believed that inhibition of AR can reduce orprevent accumulation of galactitol and resulting pathology associatedwith galactosemia.

In one example, the method for the treatment or prevention ofgalactosemia (or galactosemia complications) comprises administering toa subject in need thereof an therapeutically effective amount ofzopolrestat. In one example, the method for the treatment or preventionof galactosemia (or galactosemia complications) comprises administeringto a subject in need thereof an therapeutically effective amount ofepalrestat. In one example, the method for the treatment or preventionof galactosemia (or galactosemia complications) comprises administeringto a subject in need thereof an therapeutically effective amount of acompound of any one of Formulas I-VI. In some aspects, the AR inhibitoradministered is not ponalrestat, epalrestat, sorbinil or sorbinol,imirestat, AND-138, CT-112, zopolrestat, zenarestat, BAL-AR18, AD-5467,M-79175, tolrestat, alconil, statil, berberine or SPR-210.

The subject to be treated in accordance with the methods disclosedherein can have increased alditol levels in blood, urine or intraocularfluid, such as elevated galactitol, myoinositol or sorbitol levels inblood, urine or intraocular fluid. The subject to be treated inaccordance with the methods disclosed herein can have complications ormanifestations of galactosemia that include liver cirrhosis, retinaldisorder, macular edema, eye cataract, ovarian dysfunction, muscle ornerve dysfunction, retinopathy, neuropathy, cognitive dysfunction, motorataxia, seizure, pseudomotor cerebrii, speech dysfunction impairedneural conduction or mental retardation. In another embodiment, thedisclosure relates to a method of treating or preventing complicationsassociated with galactosemia in a subject in need thereof comprising,administering an therapeutically effective amount of a pharmaceuticalcomposition comprising AR inhibitor and a pharmaceutically acceptablecarrier. The disclosure relates to a method of reducing the amount orlevel of galactitol in a subject with galactosemia, comprisingadministering a therapeutically effective amount of an aldose reductaseinhibitor to the subject.

The disclosure relates to a method for treating cataracts, comprisingadministering a therapeutically effective amount of an aldose reductaseinhibitor to a subject in need thereof. Preferrably, the subject in needthereof has galactosemia.

The disclosure relates to a method for treating or preventing cognitiveor neurological deficiency associated with galactosemia, comprisingadministering a therapeutically effective amount of an aldose reductaseinhibitor to a subject with galactosemia. In embodiments, the cognitiveor neurological deficiency associated with galactosemia is speechdysfunction. In embodiments, the cognitive or neurological deficiencyassociated with galactosemia is motor ataxia. In embodiments, thecognitive or neurological deficiency associated with galactosemia iscognitive dysfunction. In embodiments, the cognitive or neurologicaldeficiency associated with galactosemia is pseudomotor cerebrii. Inembodiments, the cognitive or neurological deficiency associated withgalactosemia is seizure.

In another embodiment, the disclosure relates to a method of treating orpreventing galactosemia in a subject in need thereof comprising,administering an therapeutically effective amount of

(a) a first pharmaceutical composition comprising a compound of FormulasI-VI and a pharmaceutically acceptable carrier; and(b) a second pharmaceutical composition comprising alponalrestat,epalrestat, sorbinil or sorbinol, imirestat, AND-138, CT-112,zopolrestat, zenarestat, BAL-AR18, AD-5467, M-79175, tolrestat, alconil,statil, berberine or SPR-210 and a pharmaceutically acceptable carrier.

In another embodiment, disclosed herein is a use of an AR inhibitor forinhibiting the production of alditol (e.g., galactitol) for therapy ofgalactosemia.

In another embodiment, disclosed herein is use of an AR inhibitor forthe manufacture of a medicament for treating galactosemia or a clinicalmanifestation of galactosemia selected from cataracts and primaryovarian insufficiency (POI).

The disclosure also relates to the use of an AR inhibitor (e.g.,zopolrestat, epalrestat, compound of any one of Formulas I-VI) for thetreatment of galactosemia and/or the treatment and prevention ofcomplications associated with galactosemia.

The disclosure also relates to an AR inhibitor (e.g., zopolrestat,epalrestat, compound of any one of Formulas I-VI) for the manufacture ofa medicament for treatment of galactosemia and/or the treatment andprevention of complications associated with galactosemia.

The disclosure also relates to a pharmaceutical formulation fortreatment of galactosemia and/or the treatment and prevention ofcomplications associated with galactosemia, that contains an ARinhibitor (e.g., zopolrestat, epalrestat, compound of any one ofFormulas I-VI) as an active ingredient.

DETAILED DESCRIPTION

Various aspects now will be described more fully hereinafter. Suchaspects may, however, be embodied in many different forms and should notbe construed as limited to the embodiments set forth herein; rather,these embodiments are provided so that this disclosure will be thoroughand complete.

This disclosure relates to the use of AR inhibitors for the treatment ofgalactosemia. The methods described herein are based in part on theinventor's insights into the role of AR activity in the pathophysiologyof galactosemia. In normal subjects, AR primarily catalyzes thereduction of glucose to sorbitol (the first step in polyol pathway ofglucose metabolism). However, in subjects who have elevated levels ofgalactose, due to a defective Leloir pathway (e.g., due to deficiency orinsufficiency of the associated enzymes) and/or other reasons (e.g., dueto over-consumption of lactose, diabetes, endogenous production ofgalactose), excess galactose is converted into galactitol by the AR. Thegalactitol produced by this mechanism accumulates in cells becausegalactitol is not a substrate for the next enzyme in the polyol pathway,sorbitol dehydrogenase. This accumulation of galactitol causes orcontributes to the pathophysiological events in galactosemic tissues,such as, hypertonicity, sugar imbalance, oxidative stress, and the like.Accordingly, this disclosure relates to methods for treating orpreventing galactosemia or complications of galactosemia byadministering an therapeutically effective amount of an AR inhibitor toa subject in need thereof. Without wishing to be bound by any particulartheory, it is believed that inhibition of AR can reduce or preventaccumulation of galactitol and resulting pathology and complicationsassociated with galactosemia. These complications may be mediated, inpart, via increased synthesis of galactitol and/or increasedaccumulation of galactitol (e.g., due to deficiency or insufficiency inthe enzymes of the Leloir pathway, elevated galactose levels, aberrantAR activity, reduced excretion of galactitol from the tissues (e.g., dueto kidney disorders)). Inhibition of aldose reductase can reduce thesynthesis and buildup of galactitol in tissues and resulting pathologyand complications associated with galactosemia. Accordingly, the presentdisclosure further relates to the use of galactitol as a biomarker ofaldose reductase inhibition, and also, as a biomarker for monitoring theinitiation, progression, and manifestation of galactosemia.

Where a range of values is provided in this disclosure, it is intendedthat each intervening value between the upper and lower limit of thatrange and any other stated or intervening value in that stated range isencompassed within the disclosure. For example, if a range of 1 μM to 8μM is stated, it is intended that 2 μM, 3 μM, 4 μM, 5 μM, 6 μM, and 7 μMare also explicitly disclosed, as well as the range of values greaterthan or equal to 1 μM and the range of values less than or equal to 8μM.

The singular forms “a,” “an,” and “the” include plural referents unlessthe context clearly dictates otherwise. Thus, for example, reference toa “compound of Formula I” includes a single compound as well as two ormore of the same or different compounds; reference to an “excipient”includes a single excipient as well as two or more of the same ordifferent excipients, and the like.

The word “about” means a range of plus or minus 10% of that value, e.g.,“about 50” means 45 to 55, “about 25,000” means 22,500 to 27,500, etc.,unless the context of the disclosure indicates otherwise, or isinconsistent with such an interpretation. For example in a list ofnumerical values such as “about 49, about 50, about 55, “about 50” meansa range extending to less than half the interval(s) between thepreceding and subsequent values, e.g., more than 49.5 to less than 52.5.Furthermore, the phrases “less than about” a value or “greater thanabout” a value should be understood in view of the definition of theterm “about” provided herein.

In order to provide a complete, concise and clear description of thevarious embodiments, this disclosure includes descriptions of variouscomponents, groups of components, ranges and other elements of thebroader disclosure. It is intended that such elements can be variouslycombined to provide additional embodiments of the disclosure. It is alsointended that any disclosed features (e.g., substituent, analog,compound, structure, component) including individual members of anydisclosed group, including any sub-ranges or combinations of sub-rangeswithin the group, may be excluded from the disclosure or any embodimentsof the disclosure for any reason.

The various embodiments of the present disclosure are further describedin detail in the numbered paragraphs below.

I. Methods

In general, the disclosure relates to a method for the treatment ofgalactosemia (or galactosemia complications), comprising administeringto a subject in need thereof an therapeutically effective amount of acompound that inhibits aldose reductase activity. The method isparticularly useful for the treatment and/or prevention of complicationsassociated with galactosemia. The compound can be any suitable compoundthat inhibits AR activity, such as a small molecule compound (e.g.,having a size of 5 kDa or less), a biologic agent (e.g., an inhibitoryRNA directed against aldose reductase) or a combination thereof.Preferably, the AR inhibitor is a small molecule compound. Suitablesmall molecule AR inhibitors are known in the art and are disclosedherein. Small molecule AR inhibitors include ponalrestat, sorbinil,sorbinol, imirestat, AND-138, CT-112, zenarestat, BAL-AR18, AD-5467,M-79175, tolrestat, alconil, statil, berberine, SPR-210 zopolrestat,epalrestat, the compounds disclosed in U.S. Pat. Nos. 8,916,563,9,650,383, and the compounds disclosed herein. Preferred AR inhibitorsfor use in the invention include zopolrestat, epalrestat, the compoundsdisclosed in U.S. Pat. Nos. 8,916,563, 9,650,383, and the compoundsdisclosed herein. The AR inhibitors can be administered in any molecularsuitable form including pharmaceutically acceptable salts, solvates,prodrugs, and compounds that contain stable isotopic forms of one ormore atoms, e.g., deuterium in place of hydrogen.

In one example, the method for the treatment of galactosemia (orgalactosemia complications), comprises administering to a subject inneed thereof an therapeutically effective amount of zopolrestat. Thus,the disclosure provide a method for the treatment of galactosemia andprevention of galactosemia complications in a patient with galactosemiaand comprises administered to a subject in need thereof atherapeutically effective amount of zopolrestat.

In one example, the method for the treatment of galactosemia (orgalactosemia complications), comprises administering to a subject inneed thereof an therapeutically effective amount of epalrestat. Thus,the disclosure provide a method for the treatment of galactosemia andprevention of galactosemia complications in a patient with galactosemiaand comprises administered to a subject in need thereof atherapeutically effective amount of epalrestat.

In one example, the method for the treatment of galactosemia (orgalactosemia complications), comprises administering to a subject inneed thereof an therapeutically effective amount of an aldose reductase,wherein the aldose reductase inhibitor is not ponalrestat, epalrestat,sorbinil or sorbinol, imirestat, AND-138, CT-112, zopolrestat,zenarestat, BAL-AR18, AD-5467, M-79175, tolrestat, alconil, statil,berberine or SPR-210.

In one example, the method for the treatment of galactosemia (orgalactosemia complications), comprises administering to a subject inneed thereof an therapeutically effective amount of a compound of anyone of Formulas I-VI. Thus, the disclosure provide a method for thetreatment of galactosemia and prevention of galactosemia complicationsin a patient with galactosemia and comprises administering to a subjectin need thereof a therapeutically effective amount of a compound of anyone of Formulas I-VI. In certain examples, the compound that isadministered is Compound A or the compound that is administered isCompound B.

As used herein, the term “treating” refers to curative or palliative(e.g., control or mitigate a disease or disease symptoms) therapy. Thiscan include reversing, reducing, arresting or delaying the symptoms,clinical signs, and underlying pathology of galactosemia in a manner toimprove or stabilize a subject's condition. The term “preventing” withinthe context of the present method, refers to a prophylactic treatment ofan individual with galactosemia, e.g., to prevent complications (e.g.,symptom and clinical signs) associated with galactosemia. For example, afamily history or predisposition to diabetes can indicate that thesubject is at risk for galactosemia and related complications. Thus, themethod can be used for treatment of galactosemia, treatment ofcomplications (e.g., symptoms and clinical signs) of galactosemia,and/or treatment and prevention of complications (e.g., symptoms andclinical signs) of galactosemia.

As used herein “a therapeutically effective amount” is an amount of acompound that is sufficient to achieve the desired therapeutic effectunder the conditions of administration, such as an amount that reducesor ameliorates the severity and/or duration of galactosemia or one ormore clinical manifestations thereof (e.g., cataracts or primary ovarianinsufficiency (POI)), that prevents the advancement of conditions orsymptoms related to galactosemia, or enhances or otherwise improvestherapeutic effect(s) of another therapy for the treatment or managementof galactosemia (e.g., hormonal therapy in the case of POI or surgery inthe case of cataracts). A therapeutically effective amount can be anamount that reduces and preferably normalizes the amount or level ofgalactose or a galactose metabolite, in particular galactitol, in thesubject being treated. The actual amount administered can be determinedby an ordinarily skilled clinician based upon, for example, the subjectsage, weight, sex, general heath and tolerance to drugs, severity ofdisease, dosage form selected, route of administration and otherfactors. Typically, the amount of an AR inhibitor that is administeredis from about 0.5 to about 60 mg/kg body weight per day, such as fromabout 1.0 to 10 mg/kg.

In some examples of the practice of the methods disclosed herein, thetherapeutically effective amount is an amount sufficient to reduceintracellular aldose reductase activity at least by about 20%, about30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%,about 95%, about 99%, or more, e.g., about 100% (e.g., compared topre-treatment level). The therapeutically effective amount can be anamount that reduces intracellular galactitol levels at least by about20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%,about 90%, about 95%, about 99%, or more, e.g., about 100% (e.g.,compared to pre-treatment level). The therapeutically effective amountcan be an amount that reduces plasma galactitol concentration to lessthan 200 μM, particularly less than 100 μM, especially less than 50 μM,and preferably less than 10 μM in a human subject with galactosemia.Plasma galactitol levels are elevated in untreated classicalgalactosemia patients (120-500 μmol/l) compared to controls (0.08-0.86μmol/l). (Jakobs et al., Eur J Pediatr., 154(7 Suppl 2):S50-2, 1995).The therapeutically effective amount can be sufficient to restore aphysiological trait that is diminished in galactosemia, e.g., diminishedeyesight in the case of cataractic subjects or reduced estrogen levelsin a subject with POI. A therapeutically effective amount of an aldosereductase inhibitor can be an amount that is sufficient to normalizegalactitol levels in tissues (e.g., liver galactitol levels, braingalactitol levels) or the blood (plasma).

A “subject” can be any animal, particularly a mammal, and including, butby no means limited to, humans, domestic animals, such as feline orcanine subjects, farm animals, such as but not limited to bovine,equine, caprine, ovine, avian and porcine subjects, wild animals(whether in the wild or in a zoological garden), research or laboratoryanimals, such as mice, rats, rabbits, goats, sheep, pigs, dogs, cats,etc., avian species, such as chickens, turkeys, songbirds, and the like.Preferably, the “subject” is a human who is predisposed to (due togenetic aberration) or has been diagnosed with galactosemia. Typically,a human subject to be treated using the methods disclosed herein isdiagnosed with galactosemia as a new born through enzymatic or geneticscreening, and has deficiency in GALT activity, GALK activity or GALEactivity.

This disclosure also relates to the prophylaxis or treatment of at leastone clinical feature or complication of galactosemia in a subject.Representative clinical features or complications which can be presentin children, adolescents or adults, include, e.g., liver dysfunction,susceptibility to infections, failure to thrive, cataracts, retinopathy,neuropsychological and ovarian problems. For example, the disclosurerelates to treatment of at least one trait of galactosemic subjectsselected from jaundice (incidence: 74% of subjects), vomiting (47% ofsubjects), hepatomegaly (43% of subjects), failure to thrive (29% ofsubjects), poor feeding (23% of subjects), lethargy (16% of subjects),diarrhea (12% of subjects), sepsis (10% of subjects), more specifically,E. coli sepsis (76% of sepsis), coagulopathy, ascites, seizures,hepatomegaly, hypotonia, edema, full fontanelle, encephalopathy, andexcessive bruising or bleeding, primary ovarian insufficiency andpremature ovarian failure (POF). Additionally, galactosemic patients mayhave low bone density. Preferably, the clinical feature is lenticularcataracts, retinopathy, or ovarian dysfunction (e.g., primary ovarianinsufficiency (POI) or premature ovarian failure (POF)). See, Berry etal. “Classic Galactosemia and Clinical Variant Galactosemia,” inGeneReviews, Pagon R A, Adam M P, Ardinger H H, et al. Eds. Universityof Washington, Seattle, 2017.

Patients with galactosemia can experience long-term neurological andcognitive complications, even when the disease is diagnosed early and ismanaged with a galactose-restricted diet. Such complications arevariable, and include, below average IQ, impaired executive function,tremor, ataxia, dysarthria, apraxia of speech, depression and anxiety.Accordingly, additional preferred clinical features of galactosemia thatcan be treated or prevented using the methods described herein areneurological and cognitive deficiencies, such as central nervous systemdeficiencies including speech dysfunctions (e.g., delayed or impairedspeech), motor ataxia, seizure, pseudomotor cerebrii and cognitivedysfunction (e.g., low IQ (IQ below about 85)).

In a particular aspect, the disclosure relates to a method for thetreatment of a clinical feature or complication of galactosemia andcomprises administering to a subject in need thereof an therapeuticallyeffective amount of zopolrestat.

In one example, the disclosure relates to a method for the treatment ofa clinical feature or complication of galactosemia and comprisesadministering to a subject in need thereof an therapeutically effectiveamount of epalrestat.

In one example, the disclosure relates to a method for the treatment ofa clinical feature or complication of galactosemia and comprisesadministering to a subject in need thereof an therapeutically effectiveamount of a compound of any one of Formulas I-VI.

In embodiments, the clinical feature or complication of galactosemia tobe treated or prevented is retinopathy or cataracts. Presenile cataractsare a common complication in patients with galactosemia, and inparticular embodiments, the method is a method for treating cataracts.The cataracts can be subcapsular cataracts occurring at the back of thelens, nuclear cataracts which form in the central zone (nucleus) of thelens, and cortical (spoke-like) cataracts affecting the lens cortex. Themethods are also useful in the treatment of cataracts that have been orare being treated with surgery, cataracts that occur after surgicalremoval of an existing opacified lens, i.e., secondary cataracts,cataracts that occur after retinal detachment and surgery to repair theretinal detachment, cataracts associated with trauma to the eye or head,cataracts associated with tumors, cataracts associated with exposure toradiation, and cataracts associated with sugar toxicity. The presentmethods are also useful in the prophylactic treatment of cataractsresulting from systemic disorders, for example, but not limited to,galactosemia.

In embodiments, the clinical feature or complication of galactosemia tobe treated or prevented is a long-term neurological and cognitivecomplication of galactosemia. Patients with galactosemia can experiencelong-term neurological and cognitive complications, even when thedisease is diagnosed early and is managed with a galactose-restricteddiet. Such complications are variable, and include below average IQ,impaired executive function, tremor, ataxia, dysarthria, apraxia ofspeech, depression and anxiety.

In embodiments, the clinical feature or complication of galactosemia tobe treated or prevented is primary ovarian insufficiency (POI) orpremature ovarian failure (POF), or a symptom related thereto. Themethod comprises administering to a subject in need thereof, a compoundof the disclosure or a composition containing the compound. POI ischaracterized by dysfunctional ovaries (e.g., inability to produceestrogen and other hormones that are important to reproductive health).Galactosemia is one of the few known causes of POI and almost all womenwith galactosemia have POI or develop it at some point in their lives.Women with POI may be more likely to get the bone disease osteoporosisor have problems with their hearts and POI can also cause infertility.See, Fridovich-Keil et al., J Inherit Metab Dis. 34(2): 357-366, 2011.Symptoms or traits associated with POI include, e.g., delayed onset ofperiod, sudden stoppage or disruption in period, malformation ofbreasts, hot flashes, affect disorders, e.g., mood swings orirritability, vaginal dryness, and/or inability to sleep.

In some aspects, the disclosure relates to a method for reducing theamount or level of galactitol in a subject, comprising administering toa subject in need thereof an therapeutically effective amount of acompound that inhibits aldose reductase activity. The method can be usedto reduce galactitol in tissues, such as liver, brain, eye, retina,and/or in the circulation (e.g., blood or plasma) and/or in urine.Preferably, the galactitol levels are normalized. Galactose levels canbe elevated in patients with galactosemia, and preferably, the method ofreducing galactitol does not cause further elevation of galactoselevels. Normal amounts or levels of galactitol are the amounts or levelspresent in health subjects who are not on a restricted diet. Such normalamounts or levels are well known and shown in Table 1.

In embodiments, the clinical feature or complication of galactosemia tobe treated or prevented is retinopathy or cataracts. Presenile cataractsare a common complication in patients with galactosemia, and inparticular embodiments, the method is a method for treating cataracts.The cataracts can be subcapsular cataracts occurring at the back of thelens, nuclear cataracts that form in the central zone (nucleus) of thelens, and cortical (spoke-like) cataracts affecting the lens cortex. Themethods are also useful in the treatment of cataracts that have been orare being treated with surgery, cataracts that occur after surgicalremoval of an existing opacified lens, i.e., secondary cataracts,cataracts that occur after retinal detachment and surgery to repair theretinal detachment, cataracts associated with trauma to the eye or head,cataracts associated with tumors, cataracts associated with exposure toradiation, and cataracts associated with sugar toxicity. The presentmethods are also useful in the prophylactic treatment of cataractsresulting from systemic disorders, for example, but not limited to,galactosemia.

In a particular aspect, the disclosure relates to a method for thetreatment or prevention of cataracts and comprises administering to asubject in need thereof a therapeutically effective amount ofzopolrestat.

In one example, the disclosure relates to a method for the treatment orprevention of cataracts and comprises administering to a subject in needthereof a therapeutically effective amount of epalrestat.

In one example, the disclosure relates to a method for the treatment orprevention of cataracts and comprises administering to a subject in needthereof a therapeutically effective amount of a compound of any one ofFormulas I-VI. In certain examples, the compound that is administered isCompound A or the compound that is administered is Compound B.

Preferably, the patient in need of therapy for the treatment orprevention of cataracts has galactosemia.

In embodiments, the clinical feature or complication of galactosemia tobe treated or prevented is a long-term neurological and cognitivecomplication of galactosemia. Patients with galactosemia can experiencelong-term neurological and cognitive complications, even when thedisease is diagnosed early and is managed with a galactose-restricteddiet. Such complications are variable, and include below average IQ,impaired executive function, tremor, ataxia, dysarthria, apraxia ofspeech, depression and anxiety.

In a particular aspect, the disclosure relates to a method for thetreatment or prevention of neurological and cognitive deficienciesassociated with galactosemia and comprises administering to a subjectwith galactosemia a therapeutically effective amount of zopolrestat. Inparticular embodiments, the neurological or cognitive deficiencyassociated with galactosemia is speech dysfunction, such as delayedspeech or impaired speech. In particular embodiments, the neurologicalor cognitive deficiency associated with galactosemia is motor ataxia. Inparticular embodiments, the neurological or cognitive deficiencyassociated with galactosemia is cognitive dysfunction, such as low IQ.In particular embodiments, the neurological or cognitive deficiencyassociated with galactosemia is pseudomotor cerebrii. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is seizure.

In one example, the disclosure relates to a method for the treatment orprevention of neurological and cognitive deficiencies associated withgalactosemia and comprises administering to a subject with galactosemiaa therapeutically effective amount of epalrestat. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is speech dysfunction, such as delayed speech or impairedspeech. In particular embodiments, the neurological or cognitivedeficiency associated with galactosemia is motor ataxia. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is cognitive dysfunction, such as low IQ. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is pseudomotor cerebrii. In particular embodiments, theneurological or cognitive deficiency associated with galactosemia isseizure.

In one example, the disclosure relates to a method for the treatment orprevention of neurological and cognitive deficiencies associated withgalactosemia and comprises administering to a subject with galactosemiaa therapeutically effective amount of a compound of any one of FormulasI-VI. In certain examples, the compound that is administered is CompoundA or the compound that is administered is Compound B. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is speech dysfunction, such as delayed speech or impairedspeech. In particular embodiments, the neurological or cognitivedeficiency associated with galactosemia is motor ataxia. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is cognitive dysfunction, such as low IQ. In particularembodiments, the neurological or cognitive deficiency associated withgalactosemia is pseudomotor cerebrii. In particular embodiments, theneurological or cognitive deficiency associated with galactosemia isseizure.

In embodiments, the clinical feature or complication of galactosemia tobe treated or prevented is primary ovarian insufficiency (POI) orpremature ovarian failure (POF), or a symptom related thereto. Themethod comprises administering to a subject in need thereof, a compoundof the disclosure or a composition containing the compound. POI ischaracterized by dysfunctional ovaries (e.g., inability to produceestrogen and other hormones, which are important to reproductivehealth). Galactosemia is one of the few known causes of POI and almostall women with galactosemia have POI or develop it at some point intheir lives. Women with POI may be more likely to get the bone diseaseosteoporosis or have problems with their hearts and POI can causeinfertility. See, Fridovich-Keil et al., J Inherit Metab Dis. 34(2):357-366, 2011. Symptoms or traits associated with POI include, e.g.,delayed onset of period, sudden stoppage or disruption in period,malformation of breasts, hot flashes, affect disorders, e.g., moodswings or irritability, vaginal dryness, and/or inability to sleep.

In a particular aspect, the disclosure relates to a method for thetreatment or prevention of POI or POF and comprises administering to asubject with galactosemia a therapeutically effective amount ofzopolrestat.

In one example, the disclosure relates to a method for the treatment orprevention of POI or POF and comprises administering to a subject withgalactosemia a therapeutically effective amount of epalrestat.

In one example, the disclosure relates to a method for the treatment orprevention of POI or POF and comprises administering to a subject withgalactosemia a therapeutically effective amount of a compound of any oneof Formulas I-VI. In certain examples, the compound that is administeredis Compound A or the compound that is administered is Compound B.

In some aspects, the disclosure relates to a method for reducing theamount or level of galactitol in a subject, comprising administering toa subject in need thereof an therapeutically effective amount of acompound that inhibits aldose reductase activity. The method can be usedto reduce galactitol in tissues, such as liver, brain, eye, retina,and/or in the circulation (e.g., blood or plasma) and/or in urine.Preferably, the galactitol levels are normalized. Galactose levels canbe elevated in patients with galactosemia, and preferably, the method ofreducing galactitol does not cause further elevation of galactoselevels. Normal amounts or levels of galactitol are the amounts or levelspresent in health subjects who are not on a restricted diet. Such normalamounts or levels are well known and shown in

TABLE 1 Galactitol and Galactose levels (micro Molar) in HealthySubjects (unrestricted diet)* Galactose Galactitol Plasma ~0.1-~6.3Absent to trace Erythrocytes ~0.3-~1.3 Urine ~2-~4 Absent to~50 WholeBlood Absent to~250 *See, Palmieri M, et al., Urine and PlasmaGalactitol in Patients with Galactose-l-Phosphate UridyltransferaseDeficiency Galactosemia. Metabolism 1999; 48; 10:1294-1302; Yager CT, etal, Galactitol and galactonate in red blood cells of galactosemicpatients. Molecular Genetics and Metabolism 2003; 80:283-289; Hennermanet al., Features and outcome of galactokinase deficiency in childrendiagnosed by newborn screening. 2011, J. Inherit Metab. Dis. 34:399-407;and Schadewaldt P, et al., Endogenousn galactose formation ingalactose-l-phosphate uridyltransferase deficiency. 2014, Archives ofPhysiology and Biochemistry 120(5):228-239.

In a particular aspect, the disclosure relates to a method for reducing,and preferably normalizing, the amount or level of galactitol in asubject with galactosemia and comprises administering to a subject inneed thereof a therapeutically effective amount of zopolrestat.

In one example, the disclosure relates to a method for reducing, andpreferably normalizing, the amount or level of galactitol in a subjectwith galactosemia and comprises administering to a subject in needthereof a therapeutically effective amount of epalrestat.

In one example, the disclosure relates to a method for reducing, andpreferably normalizing, the amount or level of galactitol in a subjectwith galactosemia and comprises administering to a subject in needthereof a therapeutically effective amount of a compound of any one ofFormulas I-VI. In certain examples, the compound that is administered isCompound A or the compound that is administered is Compound B.

In some embodiments, the aforementioned methods are carried out byadministering a formulation comprising a single dosage or singleadministration (e.g., as a single injection or deposition) of one ormore AR inhibitors. Alternatively, the methods are carried out byadministering formulations that are adapted for administration oncedaily, twice daily, three times daily or four times daily to a subjectin need thereof for a period of from about 2 to about 28 days, or fromabout 7 to about 10 days, or from about 7 to about 15 days, or longer.In some embodiments, the methods are carried out by administeringformulations that are adapted for chronic administration. In yet otherembodiments, the methods are carried out by administering formulationsthat are adapted for administration over the course of several weeks,months, years or decades. In still other embodiments, the methods arecarried out by administering formulations that are adapted foradministration over the course of several weeks. In still otherembodiments, the methods are carried out by administering formulationsthat are adapted for administration over the course of several months.In still other embodiments, the methods are carried out by administeringformulations that are adapted for administration over the course ofseveral years. In still other embodiments, the methods are carried outby administering formulations that are adapted for administration overthe course of several decades.

II. AR Inhibitors

Suitable small molecule AR inhibitors are known in the art and aredisclosed herein. Small molecule AR inhibitors include ponalrestat,sorbinil, sorbinol, imirestat, AND-138, CT-112, zenarestat, BAL-AR18,AD-5467, M-79175, tolrestat, alconil, statil, berberine, SPR-210,zopolrestat, epalrestat, the compounds disclosed in U.S. Pat. Nos.8,916,563, 9,650,383, WO2012/009553 and the compounds disclosed herein.Preferred AR inhibitors for use in the invention zopolrestat,epalrestat, the compounds disclosed in U.S. Pat. Nos. 8,916,563,9,650,383, WO 2017/038505 and the compounds disclosed herein. Thedisclosures of U.S. Pat. Nos. 8,916,563, 9,650,383, WO 2012/009553, andWO 2017/038505 are incorporated by reference herein in their entirety,and disclose compounds that are suitable for use in the methodsdescribed herein.

AR Inhibitors of Formulas I and II

In one example, the AR inhibitor is a compound of Formula (I) orpharmaceutically acceptable salts, prodrugs and solvates thereof,

wherein,

R¹ is H, (C₁-C₆)-alkyl, (C₁-C₆)-hydroxyalkyl, or (C₁-C₆)-aminoalkyl;

X¹ is N or CR³;

X² is N or CR⁴;

X³ is N or CR⁵;

X⁴ is N or CR⁶; with the proviso that two or three of X¹, X², X³, or X⁴are N;

Y is a bond, C═O, C═S, C═NH, or C═N(C₁-C₄)-alkyl;

Z is

A¹ is NR¹¹, O, S or CH₂;

A² is N or CH;

A³ is NR¹¹, O, or S;

R³ through R¹⁰ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, trifluoroacetyl, (C₁-C₄)-alkyl,(C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or(C₁-C₄)-alkylsulfonyl; or two of R³ through R⁶ or two of R⁷ through R¹⁰taken together are (C₁-C₄)-alkylenedioxy; and

R¹¹ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

It will be recognized by those of skill in the art that the designationof Z is

indicates that when Z is

the compounds of formula (I) encompass

and when Z is

the compounds of formula (I) encompass

In certain embodiments, R¹ is hydrogen or (C₁-C₆)-alkyl. In certainembodiments, R¹ is hydrogen. In certain embodiments, R¹ is(C₁-C₆)-alkyl. In certain embodiments, R¹ is tert-butyl.

In certain embodiments, R³ through R¹⁰ are independently hydrogen,halogen or haloalkyl. In certain embodiments, R³ through R¹⁰ areindependently hydrogen, halogen or trihaloalkyl.

In certain embodiments, R³ through R⁶ are hydrogen.

In certain embodiments, R through R⁰ are independently hydrogen, halogenor haloalkyl. In certain embodiments, R through R¹⁰ are independentlyhydrogen, halogen or trihaloalkyl.

In certain embodiments, R⁷ and R¹⁰ are hydrogen.

In certain embodiments, R⁸ is hydrogen, halogen or haloalkyl. In certainembodiments, R⁸ is hydrogen. In certain embodiments, R⁸ is halogen. Incertain embodiments, R⁸ is haloalkyl.

In certain embodiments, R⁹ is hydrogen, halogen or haloalkyl. In certainembodiments, R⁹ is hydrogen. In certain embodiments, R⁹ is halogen. Incertain embodiments, R⁹ is haloalkyl.

In certain embodiments, Y is C═O, C═S, C═NH, or C═N(C₁-C₄)-alkyl. Incertain embodiments, Y is C═O or C═S. In certain embodiments, Y is C═O.In certain embodiments, Y is C═S. In certain embodiments, Y is C═NH, orC═N(C₁-C₄)-alkyl.

In certain embodiments, A¹ is NR¹¹, S or CH₂. In certain embodiments, A¹is NR¹¹ or O. In certain embodiments, A¹ is NR¹¹ or S. In certainembodiments, A¹ is NR¹¹. In certain embodiments, A¹ is O. In certainembodiments, A¹ is S.

In certain embodiments, A² is N or CH. In certain embodiments, A¹ is N.In certain embodiments, A¹ is CH.

In certain embodiments, A³ is O or S. In certain embodiments, A³ is O.In certain embodiments, A³ is S.

In certain embodiments, X¹ and X⁴ are nitrogen.

In certain embodiments, X¹ and X² are nitrogen.

In certain embodiments, X¹ and X³ are nitrogen.

In certain embodiments, X² and X³ are nitrogen.

In certain embodiments, X² and X⁴ are nitrogen.

In certain embodiments, X³ and X⁴ are nitrogen.

In certain embodiments, Z is

In certain embodiments, Z is

In certain embodiments, R¹ is hydrogen or (C₁-C₆)-alkyl;

X¹ and X⁴ are N;

X² is CR⁴;

X³ is CR⁵;

Y is C═O;

Z is

A¹ is NR¹¹, O, or S;

A² is N;

A³ is O, or S;

R⁴ and R⁵ are hydrogen;

R⁷ through R¹⁰ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, (C₁-C₄)-alkyl, (C₁-C₄)-alkoxy,(C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or (C₁-C₄)-alkylsulfonyl; and

R¹¹ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is hydrogen or tert-butyl;

X¹ and X⁴ are N;

X² is CR⁴;

X³ is CR⁵;

Y is C═O;

Z is

A¹ is NR¹¹, O or S;

A² is N;

A³ is O or S;

R⁴ and R⁵ are hydrogen;

R⁷ through R¹⁰ are independently hydrogen, halogen, or haloalkyl; and

R¹¹ is hydrogen, (C₁-C₄)-alkyl, or C(O)O-tert-butyl.

In certain embodiments, R¹ is hydrogen or tert-butyl;

X¹ and X⁴ are N;

X² is CH;

X³ is CH;

Y is C═O;

Z is

A¹ is NR¹¹, O or S;

A² is N;

A³ is O or S;

R⁷, R⁸ and R¹⁰ are independently hydrogen, halogen, or haloalkyl;

R⁹ is halogen, or haloalkyl; and

R¹¹ is hydrogen or methyl.

In certain embodiments, R¹ is hydrogen or tert-butyl;

X¹ and X⁴ are N;

X² is CH;

X³ is CH;

Y is C═O;

Z is

A¹ is NR¹, O or S;

A² is N;

A³ is O or S;

R⁷, R⁸ and R¹⁰ are independently hydrogen, halogen, or haloalkyl;

R⁹ is chlorine, or trifluoromethyl; and

R¹¹ is hydrogen or methyl.

In certain embodiments, the AR inhibitor is a compound of Formula (II)or pharmaceutically acceptable salt or solvate thereof:

Wherein R¹, R⁷-R⁹ and Y are as described in Formula I, and preferablewherein R¹ is hydrogen or (C₁-C₆)-alkyl and Y is C═O. Exemplarycompounds of Formula II include the following and salts thereof:

Compounds of Formula III

The AR inhibitors can be a compound of Formula (III) or pharmaceuticallyacceptable salts, pro-drugs and solvates thereof,

wherein,

R¹ is CO₂R² or CO₂ ⁻X⁺;

R² is H, (C₁-C₆)-alkyl, (C₁-C₆)-hydroxyalkyl, or (C₁-C₆)-aminoalkyl;

X¹ is H or halogen;

X² is H or halogen;

Y is a bond, C═O, C═S, C═NH, or C═N(C₁-C₄)-alkyl;

Z is

A¹ is NR⁷, O, S or CH₂;

A² is N or CH;

A³ is NR⁷, O, or S;

R³ through R⁶ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, trifluoroacetyl, (C₁-C₄)-alkyl,(C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or(C₁-C₄)-alkylsulfonyl;

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl; and

X⁺ is a counter ion.

It will be recognized by those of skill in the art that the designationof

Z is

indicates that when Z is

the compounds of Formula (III) are understood to encompass

and when Z is

the compounds of Formula (I) are understood to encompass

In certain embodiments, R¹ is CO₂R² or CO₂ ⁻X⁺. In certain embodiments,R¹ is CO₂R². In certain embodiments, R¹ is CO₂ ⁻X⁺.

In certain embodiments, R² is hydrogen or (C₁-C₆)-alkyl. In certainembodiments, R² is hydrogen or (C₁-C₄)-alkyl. In certain embodiments, R²is hydrogen or (C₁-C₃)-alkyl. In certain embodiments, R² is hydrogen,methyl, or ethyl. In certain embodiments, R² is hydrogen or methyl. Incertain embodiments, R² is methyl or ethyl. In certain embodiments, R²is methyl. In certain embodiments, R² is hydrogen. In certainembodiments, R² is (C₁-C₆)-alkyl. In certain embodiments, R² is(C₁-C₆)-n-alkyl. In certain embodiments, R² is (C₁-C₂)-alkyl. In certainembodiments, R² is (C₁-C₃)-alkyl. In certain embodiments, R² is(C₁-C₄)-alkyl. In certain embodiments, R² is tert-butyl.

In certain embodiments, R³ through R⁶ are independently hydrogen,halogen, cyano, acyl, haloalkyl, haloalkoxy, haloalkylthio,trifluoroacetyl, (C₁-C₄)-alkyl, (C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio,(C₁-C₄)-alkylsulfinyl, or (C₁-C₄)-alkylsulfonyl.

In certain embodiments, R³ through R⁶ are independently hydrogen,halogen or haloalkyl. In certain embodiments, R³ through R⁶ areindependently hydrogen, halogen or trihaloalkyl.

In certain embodiments, R³ and R⁶ are hydrogen. In certain embodiments,R³, R⁵, and R⁶ are hydrogen.

In certain embodiments, R⁴ is hydrogen, halogen or haloalkyl. In certainembodiments, R⁴ is hydrogen. In certain embodiments, R⁴ is halogen. Incertain embodiments, R⁴ is haloalkyl. In certain embodiments, R⁴ is CF₃.

In certain embodiments, R³ through R⁶ are hydrogen. In certainembodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is halogen or haloalkyl. Incertain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is haloalkyl. Incertain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is CF₃. In certainembodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is halogen. In certainembodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is F. In certainembodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is Cl.

In certain embodiments, Y is C═O, C═S, C═NH, or C═N(C₁-C₄)-alkyl. Incertain embodiments, Y is C═O or C═S. In certain embodiments, Y is C═O.In certain embodiments, Y is C═S. In certain embodiments, Y is C═NH, orC═N(C₁-C₄)-alkyl.

In certain embodiments, A¹ is NR⁷, O, S or CH₂. In certain embodiments,A¹ is NR⁷, O, or S. In certain embodiments, A¹ is NR⁷, S or CH₂. Incertain embodiments, A¹ is NR⁷ or O. In certain embodiments, A¹ is NR⁷or S. In certain embodiments, A¹ is NR⁷. In certain embodiments, A¹ isO. In certain embodiments, A¹ is S.

In certain embodiments, A² is N or CH. In certain embodiments, A² is N.In certain embodiments, A² is CH.

In certain embodiments, A³ is NR⁷, O, or S. In certain embodiments, A³is O. In certain embodiments, A³ is S. In certain embodiments, A³ isNR⁷.

In certain embodiments, X¹ and X² are hydrogen.

In certain embodiments, X¹ and X² are halogen. In certain embodiments,X¹ and X² are Cl.

In certain embodiments, X¹ and X² are independently hydrogen or halogen.In certain embodiments, X¹ is hydrogen and X² is Cl. In certainembodiments, X¹ is Cl and X² is hydrogen.

In certain embodiments, Z is

In certain embodiments, Z is

In certain embodiments, R⁷ is hydrogen, C₁-C₄ alkyl, orC(O)O—(C₁-C₄)-alkyl. In certain embodiments, R⁷ is hydrogen. In certainembodiments, R⁷ is C₁-C₄ alkyl. In certain embodiments, R⁷ is C₁-C₃alkyl. In certain embodiments, R⁷ is C₁-C₂ alkyl. In certainembodiments, R⁷ is C₁-C₄ n-alkyl. In certain embodiments, R⁷ is C₁-C₃n-alkyl. In certain embodiments, R⁷ is C(O)O—(C₁-C₄)-alkyl. In certainembodiments, R⁷ is C(O)O—(C₁-C₃)-alkyl. In certain embodiments, R⁷ isC(O)O—(C₁-C₂)-alkyl. In certain embodiments, R⁷ isC(O)O—(C₁-C₄)-n-alkyl. In certain embodiments, R⁷ isC(O)O—(C₁-C₃)-n-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or (C₁-C₆)-alkyl;

X¹ is H;

X² is H;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R³ through R⁶ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, trifluoroacetyl, (C₁-C₄)-alkyl,(C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or(C₁-C₄)-alkylsulfonyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or tert-butyl;

X¹ is H;

X² is H;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R⁶ through R⁶ are independently hydrogen, halogen, haloalkyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or tert-butyl;

X¹ is H;

X² is H;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R³, R⁵, and R⁶ are hydrogen;

R⁴ is hydrogen, halogen, or haloalkyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or (C₁-C₆)-alkyl;

X¹ is halogen;

X² is halogen;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R³ through R⁶ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, trifluoroacetyl, (C₁-C₄)-alkyl,(C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or(C₁-C₄)-alkylsulfonyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or tert-butyl;

X¹ is halogen;

X² is halogen;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R³ through R⁶ are independently hydrogen, halogen, haloalkyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or tert-butyl;

X¹ is Cl;

X² is Cl;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R³ through R⁶ are independently hydrogen, halogen, haloalkyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, R¹ is CO₂R²;

R² is H or tert-butyl;

X¹ is Cl;

X² is Cl;

Y is C═O;

Z is

A¹ is NR⁷, O, or S;

A² is N;

A³ is O or S;

R³, R⁵, and R⁶ are hydrogen;

R⁴ is hydrogen, halogen, or haloalkyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

In certain embodiments, the compound of Formula (III) is selected fromthe group consisting of:

In certain embodiments, the compound of Formula (I) is

or a pharmaceutically acceptable salt thereof.

In certain embodiments, the compound of formula (I) is

or a pharmaceutically acceptable salt thereof.

Compounds of Formulas IV, V and VI

The AR inhibitors can be a compound of Formula (IV) or pharmaceuticallyacceptable salts, and solvates thereof,

wherein,

X¹ is H or halogen;

X² is H or halogen;

Y is a bond, C═O, C═S, C═NH, or C═N(C₁-C₄)-alkyl;

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene;

Z is

A¹ is NR⁷, O, S or CH₂;

A² is N or CH;

A³ is NR⁷, O, or S;

R³ through R⁶ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, trifluoroacetyl, (C₁-C₄)-alkyl,(C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or(C₁-C₄)-alkylsulfonyl; and

R⁷ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

Suitable substituents on the C₂-C₅ alkylene include one or more alkyl,alkoxy, aryl, aryloxy, halo, haloalkyl, haloalkoxy, haloalkylthio. Apreferred substituted C₂-C₅ alkylene is substituted ethylene. A morepreferred substituted C₂-C₅ alkylene is —C(CH₃)₂C(CH₃)₂—.

It will be recognized by those of skill in the art that the designationof

Z is

or Z is

indicates that when Z is

the compounds of Formula (IV) are understood to encompass

and

when Z is

the compounds of Formula (IV) are understood to encompass

wherein,

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In certain embodiments, R³ through R⁶ of Formula (IV) are independentlyhydrogen, halogen, cyano, acyl, haloalkyl, haloalkoxy, haloalkylthio,trifluoroacetyl, (C₁-C₄)-alkyl, (C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio,(C₁-C₄)-alkylsulfinyl, or (C₁-C₄)-alkylsulfonyl.

In certain embodiments, R³ through R⁶ of Formula (IV) are independentlyhydrogen, halogen or haloalkyl. In certain embodiments, R³ through R⁶are independently hydrogen, halogen or trihaloalkyl.

In certain embodiments, R³ and R⁶ of Formula (IV) are hydrogen. Incertain embodiments, R³, R⁵, and R⁶ are hydrogen.

In certain embodiments, R⁴ of Formula (IV) is hydrogen, halogen orhaloalkyl. In certain embodiments, R⁴ is hydrogen. In certainembodiments, R⁴ is halogen. In certain embodiments, R⁴ is haloalkyl. Incertain embodiments, R⁴ is CF₃.

In certain embodiments, R³ through R⁶ of Formula (IV) are hydrogen. Incertain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is halogen orhaloalkyl. In certain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ ishaloalkyl. In certain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ isCF₃. In certain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is halogen.In certain embodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is F. In certainembodiments, R³, R⁵, R⁶ are hydrogen and R⁴ is Cl.

In certain embodiments, Y of Formula (IV) is C═O, C═S, C═NH, orC═N(C₁-C₄)-alkyl. In certain embodiments, Y is C═O or C═S. In certainembodiments, Y is C═O. In certain embodiments, Y is C═S. In certainembodiments, Y is C═NH, or C═N(C₁-C₄)-alkyl.

In certain embodiments, A¹ of Formula (IV) is NR⁷, O, S or CH₂. Incertain embodiments, A¹ is NR⁷, O, or S. In certain embodiments, A¹ isNR⁷, S or CH₂. In certain embodiments, A¹ is NR⁷ or O. In certainembodiments, A¹ is NR⁷ or S. In certain embodiments, A¹ is NR⁷. Incertain embodiments, A¹ is O. In certain embodiments, A¹ is S.

In certain embodiments, A² of Formula (IV) is N or CH. In certainembodiments, A² is N. In certain embodiments, A² is CH.

In certain embodiments, A³ of Formula (IV) is NR⁷, O, or S. In certainembodiments, A³ is O. In certain embodiments, A³ of Formula (IV) is S.In certain embodiments, A³ is NR⁷.

In certain embodiments, X¹ and X² of Formula (IV) are hydrogen.

In certain embodiments, X¹ and X² of Formula (IV) are halogen. Incertain embodiments, X¹ and X² are Cl.

In certain embodiments, X¹ and X² of Formula (IV) are independentlyhydrogen or halogen. In certain embodiments, X¹ is hydrogen and X² isCl. In certain embodiments, X¹ is Cl and X² is hydrogen.

In certain embodiments, Z of Formula (IV) is

In certain embodiments, Z of Formula (IV) is

In certain embodiments, R⁷ of Formula (IV) is hydrogen, C₁-C₄ alkyl, orC(O)O—(C₁-C₄)-alkyl. In certain embodiments, R⁷ is hydrogen. In certainembodiments, R⁷ is C₁-C₄ alkyl. In certain embodiments, R⁷ is C₁-C₃alkyl. In certain embodiments, R⁷ is C₁-C₂ alkyl. In certainembodiments, R⁷ is C₁-C₄ n-alkyl. In certain embodiments, R⁷ is C₁-C₃n-alkyl. In certain embodiments, R⁷ is C(O)O—(C₁-C₄)-alkyl. In certainembodiments, R⁷ is C(O)O—(C₁-C₃)-alkyl. In certain embodiments, R⁷ isC(O)O—(C₁-C₂)-alkyl. In certain embodiments, R⁷ isC(O)O—(C₁-C₄)-n-alkyl. In certain embodiments, R⁷ isC(O)O—(C₁-C₃)-n-alkyl.

In certain embodiments, the compounds of Formula (IV) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In certain embodiments, the compounds of Formula (IV) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In certain embodiments, the compounds of Formula (IV) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In certain embodiments, the compounds of Formula (IV) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In another aspect, the aldose reductase inhibitor is a compound ofFormula (V)

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

X³ is N or CR⁸;

X⁴ is N or CR⁹;

X⁵ is N or CR¹⁰;

X⁶ is N or CR¹¹; with the proviso that two or three of X³, X⁴, X⁵, or X⁶are N;

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene;

Z³ is

A⁴ is NR¹⁶, O, S or CH₂;

A⁵ is N or CH;

A⁶ is NR¹⁶, O, or S;

R⁸ through R¹⁵ are independently hydrogen, halogen, cyano, acyl,haloalkyl, haloalkoxy, haloalkylthio, trifluoroacetyl, (C₁-C₄)-alkyl,(C₁-C₄)-alkoxy, (C₁-C₄)-alkylthio, (C₁-C₄)-alkylsulfinyl, or(C₁-C₄)-alkylsulfonyl; or two of R⁸ through R¹¹ or two of R¹² throughR¹⁵ taken together are (C₁-C₄)-alkylenedioxy; and

R¹⁶ is hydrogen, C₁-C₄ alkyl, or C(O)O—(C₁-C₄)-alkyl.

Suitable substituents on the C₂-C₅ alkylene include one or more alkyl,alkoxy, aryl, aryloxy, halo, haloalkyl, haloalkoxy, haloalkylthio. Apreferred substituted C₂-C₅ alkylene is substituted ethylene. A morepreferred substituted C₂-C₅ alkylene is —C(CH₃)₂C(CH₃)₂—.

It will be recognized by those of skill in the art that the designationof

Z is

or Z is

indicates that when Z is

the compounds of Formula (V) are understood to encompass

and when Z is

the compounds of Formula (V) are understood to encompass

In some compounds of Formula V, R⁸ through R¹⁵ are independentlyhydrogen, halogen or haloalkyl, for example, R⁸ through R¹⁵ areindependently hydrogen, halogen or trihaloalkyl (e.g., —CF₃).

In other compounds of Formula V, R⁸ through R¹¹ are hydrogen.

In certain embodiments of compounds of Formula V, R¹² through R¹⁵ areindependently hydrogen, halogen or haloalkyl, for example, R¹² throughR¹⁵ are independently hydrogen, halogen or trihaloalkyl (e.g., —CF₃).

In certain embodiments, R¹² and R¹⁵ of Formula (V) are hydrogen.

In certain embodiments, R¹³ of Formula (V) is hydrogen, halogen orhaloalkyl. In certain embodiments, R¹³ is hydrogen. In certainembodiments, R¹³ is halogen. In certain embodiments, R¹³ is haloalkyl.

In certain embodiments, R¹⁴ of Formula (V) is hydrogen, halogen orhaloalkyl. In certain embodiments, R¹⁴ is hydrogen. In certainembodiments, R¹⁴ is halogen. In certain embodiments, R¹⁴ is haloalkyl.

In certain embodiments, Y of Formula (V) is C═O, C═S, C═NH, orC═N(C₁-C₄)-alkyl. In certain embodiments, Y is C═O or C═S. In certainembodiments, Y is C═O. In certain embodiments, Y is C═S. In certainembodiments, Y is C═NH, or C═N(C₁-C₄)-alkyl.

In certain embodiments, A⁴ of Formula (V) is NR¹⁶, S or CH₂. In certainembodiments, A⁴ is NR¹⁶ or O. In certain embodiments, A⁴ is NR¹⁶ or S.In certain embodiments, A⁴ is NR¹⁶. In certain embodiments, A⁴ is O. Incertain embodiments, A⁴ is S.

In certain embodiments, A⁵ of Formula (V) is N or CH. In certainembodiments, A⁴ is N. In certain embodiments, A⁴ is CH.

In certain embodiments, A⁶ of Formula (V) is O or S. In certainembodiments, A⁶ is O. In certain embodiments, A⁶ is S.

In certain embodiments, X³ and X⁶ of Formula (V) are nitrogen.

In certain embodiments, X³ and X⁴ of Formula (V) are nitrogen.

In certain embodiments, X³ and X⁵ of Formula (V) are nitrogen.

In certain embodiments, X⁴ and X⁵ of Formula (V) are nitrogen.

In certain embodiments, X⁴ and X⁶ of Formula (V) are nitrogen.

In certain embodiments, X⁵ and X⁶ of Formula (V) are nitrogen.

In certain embodiments, Z³ of Formula (V) is

In certain embodiments, Z³ of Formula (V) is

In some embodiments, the compounds of Formula (V) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

R¹⁴ is hydrogen, halogen or trihaloalkyl (e.g., —CF₃); and

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In embodiments, the compounds of Formula (V) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof.

In one aspect, the aldose reductase inhibitor is a compound of Formula(VI)

or pharmaceutically acceptable salts, pro-drugs or solvates thereof;

wherein,

Z¹ and Z² are independently selected from the group consisting ofhydroxy, alkoxy, aryloxy, or Z¹ and Z² taken together with the boronatom to which they are bonded form

wherein,

X is a substituted or unsubstituted C₂-C₅ alkylene.

In an embodiment, the aldose reductase inhibitor of Formula (VI) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof.

In an embodiment, the AH inhibitor of Formula (VI) is

or pharmaceutically acceptable salts, pro-drugs or solvates thereof.

The term “alkyl”, as used herein, unless otherwise indicated, refers toa monovalent aliphatic hydrocarbon radical having a straight chain,branched chain, monocyclic moiety, or polycyclic moiety or combinationsthereof, wherein the radical is optionally substituted at one or morecarbons of the straight chain, branched chain, monocyclic moiety, orpolycyclic moiety or combinations thereof with one or more substituentsat each carbon, where the one or more substituents are independentlyC₁-C₁₀ alkyl. Examples of “alkyl” groups include methyl, ethyl, propyl,isopropyl, butyl, iso-butyl, sec-butyl, tert-butyl, pentyl, hexyl,heptyl, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl,norbornyl, and the like.

The term “halogen” or “halo-”, as used herein, means chlorine (Cl),fluorine (F), iodine (I) or bromine (Br).

As used herein, the term “acyl” is used in a broad sense to designateradicals of the type RCO—, in which R represents an organic radicalwhich may be an alkyl, aralkyl, aryl, alicyclic or heterocyclic radical,substituted or unsubstituted, saturated or unsaturated; or, differentlydefined, the term “acyl” is used to designate broadly the monovalentradicals left when the OH group of the carboxylic radical is removedfrom the molecule of a carboxylic acid.

The term “alkoxy” is employed to designate a group of the formula: —O—Rwherein R is an alkyl group, which optionally contains substituents,such as halogen. Preferably, the term “alkoxy” is employed to designatean alkoxy with an alkyl group of 1 to 6 carbon atoms. Most preferably,the term “alkoxy” is employed to designate an alkoxy with an alkyl groupof 1 to 3 carbon atoms, such as methoxy or ethoxy.

The term “cycloalkyl group” is used herein to identify cycloalkyl groupshaving 3-6 carbon atoms preferably cyclopropyl, cyclobutyl, cyclopentyland cyclohexyl.

The term “solvate” as used herein means a compound, or apharmaceutically acceptable salt thereof, wherein molecules of asuitable solvent are incorporated in the crystal lattice. A suitablesolvent is physiologically tolerable at the dosage administered.Examples of suitable solvents are ethanol, water and the like. Whenwater is the solvent, the molecule is referred to as a “hydrate.”

A “prodrug” refers to an agent, which is converted into the parent drugin vivo. Prodrugs are often useful because, in some situations, they areeasier to administer than the parent drug. They are bioavailable, forinstance, by oral administration whereas the parent drug is either lessbioavailable or not bioavailable. The prodrug also has improvedsolubility in pharmaceutical compositions over the parent drug. Forexample, the compound carries protective groups which are split off byhydrolysis in body fluids, e.g., in the bloodstream, thus releasingactive compound or is oxidized or reduced in body fluids to release thecompound. The term “prodrug” may apply to such functionalities as, forexample; the acid functionalities of the compounds of formula I.Prodrugs may be comprised of structures wherein an acid group is masked,for example, as an ester or amide. Further examples of prodrugs arediscussed herein. See also Alexander et al. (J. Med. Chem. 1988, 31,318), which is incorporated by reference. Examples of prodrugs include,but are not limited to, derivatives and metabolites of a compound thatinclude biohydrolyzable moieties such as biohydrolyzable amides,biohydrolyzable esters, biohydrolyzable carbamates, biohydrolyzablecarbonates, and biohydrolyzable phosphate analogues. Prodrugs are alsodescribed in, for example, The Practice of Medicinal Chemistry (CamilleWermuth, ed., 1999, Academic Press; hereby incorporated by reference inits entirety). In certain embodiments, prodrugs of compounds withcarboxyl functional groups are the lower alkyl esters of the carboxylicacid. The carboxylate esters are conveniently formed by esterifying anyof the carboxylic acid moieties present on the molecule. Prodrugs cantypically be prepared using well-known methods, such as those describedby Burger's Medicinal Chemistry and Drug Discovery 6^(th) ed. (Donald J.Abraham ed., 2001, Wiley) and Design and Application of Prodrugs (H.Bundgaard ed., 1985, Harwood Academic Publishers Gmfh; each of whichhereby incorporated by reference in its entirety). Biohydrolyzablemoieties of a compound of Formula I (a) do not interfere with thebiological activity of the compound but can confer upon that compoundadvantageous properties in vivo, such as uptake, duration of action, oronset of action; or (b) may be biologically inactive but are convertedin vivo to the biologically active compound. Examples of biohydrolyzableesters include, but are not limited to, lower alkyl esters,alkoxyacyloxy esters, alkyl acylamino alkyl esters, and choline esters.Examples of biohydrolyzable amides include, but are not limited to,lower alkyl amides, α-amino acid amides, alkoxyacyl amides, andalkylaminoalkylcarbonyl amides. Examples of biohydrolyzable carbamatesinclude, but are not limited to, lower alkylamines, substitutedethylenediamines, amino acids, hydroxyalkylamines, heterocyclic andheteroaromatic amines, and polyether amines.

The term “salt” includes salts derived from any suitable of organic andinorganic counter ions well known in the art and include, by way ofexample, hydrochloric acid salt or a hydrobromic acid salt or analkaline or an acidic salt of the aforementioned amino acids. The termis intended to include salts derived from inorganic or organic acidsincluding, for example hydrochloric, hydrobromic, sulfuric, nitric,perchloric, phosphoric, formic, acetic, lactic, maleic, fumaric,succinic, tartaric, glycolic, salicylic, citric, methanesulfonic,benzenesulfonic, benzoic, malonic, trifluoroacetic, trichloroacetic,naphthalene-2 sulfonic and other acids; and salts derived from inorganicor organic bases including, for example sodium, potassium, calcium,ammonium or tetrafluoroborate. Exemplary pharmaceutically acceptablesalts are found, for example, in Berge, et al. (J. Pharm. Sci. 1977,66(1), 1; and U.S. Pat. Nos. 6,570,013 and 4,939,140; each herebyincorporated by reference in its entirety). Pharmaceutically acceptablesalts are also intended to encompass hemi-salts, wherein the ratio ofcompound:acid is respectively 2:1. Exemplary hemi-salts are those saltsderived from acids comprising two carboxylic acid groups, such as malicacid, fumaric acid, maleic acid, succinic acid, tartaric acid, glutaricacid, oxalic acid, adipic acid and citric acid. Other exemplaryhemi-salts are those salts derived from diprotic mineral acids such assulfuric acid. Exemplary preferred hemi-salts include, but are notlimited to, hemimaleate, hemifumarate, and hemisuccinate.

The term “acid” contemplates all pharmaceutically acceptable inorganicor organic acids. Inorganic acids include mineral acids such ashydrohalic acids, such as hydrobromic and hydrochloric acids, sulfuricacids, phosphoric acids and nitric acids. Organic acids include allpharmaceutically acceptable aliphatic, alicyclic and aromatic carboxylicacids, dicarboxylic acids, tricarboxylic acids, and fatty acids.Preferred acids are straight chain or branched, saturated or unsaturatedC₁-C₂₀ aliphatic carboxylic acids, which are optionally substituted byhalogen or by hydroxyl groups, or C₆-C₁₂ aromatic carboxylic acids.Examples of such acids are carbonic acid, formic acid, fumaric acid,acetic acid, propionic acid, isopropionic acid, valeric acid,alpha-hydroxy acids, such as glycolic acid and lactic acid, chloroaceticacid, benzoic acid, methane sulfonic acid, and salicylic acid. Examplesof dicarboxylic acids include oxalic acid, malic acid, succinic acid,tartaric acid and maleic acid. An example of a tricarboxylic acid iscitric acid. Fatty acids include all pharmaceutically acceptablesaturated or unsaturated aliphatic or aromatic carboxylic acids having 4to 24 carbon atoms. Examples include butyric acid, isobutyric acid,sec-butyric acid, lauric acid, palmitic acid, stearic acid, oleic acid,linoleic acid, linolenic acid, and phenylsteric acid. Other acidsinclude gluconic acid, glycoheptonic acid and lactobionic acid.

III. Compositions

The compounds can be administered in the form a suitable composition,such as a pharmaceutical composition. Pharmaceutical compositions arephysiologically acceptable and typically include the active compound anda carrier. The term “carrier” refers to a diluent, adjuvant, excipient,or vehicle with which a compound is administered. Non-limiting examplesof such pharmaceutical carriers include liquids, such as water and oils,including those of petroleum, animal, vegetable or synthetic origin,such as peanut oil, soybean oil, mineral oil, sesame oil and the like.The pharmaceutical carriers may also be saline, gum acacia, gelatin,starch paste, talc, keratin, colloidal silica, urea, and the like. Inaddition, auxiliary, stabilizing, thickening, lubricating and coloringagents may be used. Other examples of suitable pharmaceutical carriersare described in Remington's Pharmaceutical Sciences (Alfonso Gennaroed., Krieger Publishing Company (1997); Remington's: The Science andPractice of Pharmacy, 21S^(t)Ed. (Lippincot, Williams & Wilkins (2005);Modern Pharmaceutics, vol. 121 (Gilbert Banker and Christopher Rhodes,CRC Press (2002); each of which hereby incorporated by reference in itsentirety). Particularly, the carrier can be suitable for ocularapplications, e.g., application into the eye for the treatment of eyediseases, e.g., cataract. In another embodiment, the carrier maycomprise a suppository for vaginal administration, e.g., for thetreatment of premature ovarian insufficiency (POI).

The composition can be in a desired form, such as a table, capsule,solution, emulsion, suspension, gel, sol, or colloid that isphysiologically and/or pharmaceutically acceptable. If desired, thecarrier can include a buffer, for example with alkaline buffers, e.g.,ammonium buffer, acidic buffers, e.g., ethanoates, citrates, lactates,acetates, etc., or zwitterionic buffers, such as, glycine, alanine,valine, leucine, isoleucine and phenylalanine, Kreb's-Ringer buffer,TRIS, MES, ADA, ACES, PIPES, MOPSO, cholamine chloride, MOPS, BES, TES,HEPES, DIPSO, MOBS, TAPSO, acetamidoglycine, TEA, POPSO, HEPPSO, EPS,HEPPS, Tricine, TRIZMA, Glycinamide, Glycyl-glycine, HEPBS, Bicine,TAPS, AMPB, CHES, AMP, AMPSO, CAPSO, CAPS, and CABS.

In embodiments where the composition is in a liquid form, a carrier canbe a solvent or dispersion medium comprising but not limited to, water,ethanol, polyol (e.g., glycerol, propylene glycol, liquid polyethyleneglycol, etc.), lipids (e.g., triglycerides, vegetable oils, liposomes)and combinations thereof. The proper fluidity can be maintained, forexample, by the use of a coating, such as lecithin; by the maintenanceof the required particle size by dispersion in carriers such as, forexample liquid polyol or lipids; by the use of surfactants such as, forexample hydroxypropylcellulose; or combinations thereof such methods. Ifdesired tonicity adjusting agents can be included, such as, for example,sugars, sodium chloride or combinations thereof. In some embodiments,the composition is isotonic.

The compositions may also include additional ingredients, such asacceptable surfactants, co-solvents, emollients, agents to adjust the pHand osmolarity and/or antioxidants to retard oxidation of one or morecomponent.

The compositions can be prepared for administration by any suitableroute such as ocular (including periocular and intravitrealadministration), oral, parenteral, intranasal, anal, vaginal, topical,subcutaneous, intravenous, intra-arterial, intrathecal andintraperitoneal administration. As shown in the working examplesdisclosed herein, oral administration of aldose reductase inhibitorseffectively lowered and normalized galactitol levels in blood andtissues, include brain. Accordingly, while intrathecal administration isan option and may be selected by a clinician (e.g., when the aldosereductase inhibitor is not central nervous system penetrant), it isgenerally preferred that the aldose reductase inhibitor is notadministered intrathecally. For ocular administration, the compositionmay be formulated as, for example, drops, solutions, suspensions,emulsions, ointments, sustained release formulation, troche, elixir,syrup, wafer, powder or combinations thereof. See, Gaudana et al., AAPSJ., 12(3): 348-360, 2010. Oral compositions may be incorporated directlywith the food of the diet. Preferred carriers for oral administrationcomprise inert diluents, edible carriers or combinations thereof.Examples of pharmaceutically acceptable carriers may include, forexample, water or saline solution, polymers such as polyethylene glycol,carbohydrates and derivatives thereof, oils, fatty acids, or alcohols.Surfactants such as, for example, detergents, are also suitable for usein the formulations. Specific examples of surfactants includepolyvinylpyrrolidone, polyvinyl alcohols, copolymers of vinyl acetateand of vinylpyrrolidone, polyethylene glycols, benzyl alcohol, mannitol,glycerol, sorbitol or polyoxyethylenated esters of sorbitan; lecithin orsodium carboxymethylcellulose; or acrylic derivatives, such asmethacrylates and others, anionic surfactants, such as alkalinestearates, in particular sodium, potassium or ammonium stearate; calciumstearate or triethanolamine stearate; alkyl sulfates, in particularsodium lauryl sulfate and sodium cetyl sulfate; sodiumdodecylbenzenesulphonate or sodium dioctyl sulphosuccinate; or fattyacids, in particular those derived from coconut oil, cationicsurfactants, such as water-soluble quaternary ammonium salts of formulaNR′R″R′″R″″Y″, in which the R radicals are identical or differentoptionally hydroxylated hydrocarbon radicals and Y″ is an anion of astrong acid, such as halide, sulfate and sulfonate anions;cetyltrimethylammonium bromide is one of the cationic surfactants whichcan be used, amine salts of formula NR′R′R″, in which the R radicals areidentical or different optionally hydroxylated hydrocarbon radicals;octadecylamine hydrochloride is one of the cationic surfactants whichcan be used, non-ionic surfactants, such as optionallypolyoxyethylenated esters of sorbitan, in particular Polysorbate 80, orpolyoxyethylenated alkyl ethers; polyethylene glycol stearate,polyoxyethylenated derivatives of castor oil, polyglycerol esters,polyoxyethylenated fatty alcohols, polyoxyethylenated fatty acids orcopolymers of ethylene oxide and of propylene oxide, amphotericsurfactants, such as substituted lauryl compounds of betaine.

If desired, an oral composition may comprise one or more binders,excipients, disintegration agents, lubricants, flavoring agents, andcombinations thereof. In certain embodiments, a composition may compriseone or more of the following: a binder, such as, for example, gumtragacanth, acacia, cornstarch, gelatin or combinations thereof; anexcipient, such as, for example, dicalcium phosphate, mannitol, lactose,starch, magnesium stearate, sodium saccharine, cellulose, magnesiumcarbonate or combinations thereof; a disintegrating agent, such as, forexample, corn starch, potato starch, alginic acid or combinationsthereof; a lubricant, such as, for example, magnesium stearate; asweetening agent, such as, for example, sucrose, lactose, saccharin orcombinations thereof; a flavoring agent, such as, for examplepeppermint, oil of wintergreen, cherry flavoring, orange flavoring,etc., or combinations thereof containing two or more of the foregoing.

Additional formulations which are suitable for other modes ofadministration include suppositories. Moreover, sterile injectablesolutions may be prepared using an appropriate solvent. Generally,dispersions are prepared by incorporating the various sterilized aminoacid components into a sterile vehicle, which contains the basicdispersion medium and/or the other ingredients. Suitable formulationmethods for any desired mode of administration are well known in the art(see, generally, Remington's Pharmaceutical Sciences, 18^(th) Ed. MackPrinting Company, 1990).

Typical pharmaceutically acceptable compositions can contain a an ARinhibitor and/or a pharmaceutically acceptable salt thereof at aconcentration ranging from about 0.01 to about 2 wt %, such as 0.01 toabout 1 wt % or about 0.05 to about 0.5 wt %. The composition can beformulated as a solution, suspension, ointment, or a capsule, and thelike. The pharmaceutical composition can be prepared as an aqueoussolution and can contain additional components, such as preservatives,buffers, tonicity agents, antioxidants, stabilizers, viscosity-modifyingingredients and the like. Other equivalent modes of administration canbe found in U.S. Pat. No. 4,939,140.

When administered to a subject, the AR inhibitor and pharmaceuticallyacceptable carriers can be sterile. Suitable pharmaceutical carriers mayalso include excipients such as starch, glucose, lactose, sucrose,gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glycerolmonostearate, talc, sodium chloride, dried skim milk, glycerol,propylene, glycol, polyethylene glycol 300, water, ethanol, polysorbate20, and the like. The present compositions, if desired, may also containminor amounts of wetting or emulsifying agents, or pH buffering agents.

The pharmaceutical formulations of the present disclosure are preparedby methods well-known in pharmaceutics. Optionally, one or moreaccessory ingredients (e.g., buffers, flavoring agents, surface activeagents, and the like) also are added. The choice of carrier isdetermined by the solubility and chemical nature of the compounds,chosen route of administration and standard pharmaceutical practice.

In some embodiments, the composition is in unit dose form such as atablet, capsule or single-dose vial. Suitable unit doses, i.e.,therapeutically effective amounts, may be determined during clinicaltrials designed appropriately for each of the conditions for whichadministration of a chosen compound is indicated and will, of course,vary depending on the desired clinical endpoint.

Any of the compounds and/or compositions of the disclosure may beprovided in a kit comprising the compounds and/or compositions. Thus, inone embodiment, the compound and/or composition of the disclosure isprovided in a kit comprising in the same package or separate package, acarrier and optionally instructions for using the kit for therapeutic orprophylactic end usage.

IV. Combination therapy

The methods described herein include the administration of an ARinhibitor and one more additional therapeutic agents. The additionaltherapeutic agents may be administered before, concurrently with orafter the AR inhibitor, but in a manner that provides for overlap of thepharmacological activity of the AR inhibitor and the additionaltherapeutic agent. The additional therapeutic agent can be, for example,second aldose reductase inhibitor, an antioxidant, or both.

For example, the 2^(nd) aldose reductase can be a compound described in,for example, in U.S. Pat. Nos. 5,677,342; 5,155,259; 4,939,140; USUS2006/0293265; and Roy et al. (Diabetes Research and Clinical Practice,10, Issue 1, 91-97, 1990; and references cited therein; each of whichhereby incorporated by reference in its entirety. Aldose reductaseinhibitors include, for example, zopolrestat, epalrestat, ranirestat,berberine and sorbinil, as described in, e.g., U.S. Pat. Nos. 4,939,140;6,159,976; and 6,570,013. Preferably, the 2^(nd) aldose reductaseinhibitor is selected from ponalrestat, epalrestat, sorbinil orsorbinol, imirestat, AND-138, CT-112, zopolrestat, zenarestat, BAL-AR18,AD-5467, M-79175, tolrestat, alconil, statil, berberine or SPR-210.

Other therapeutic agents that can be administered include, for examplecorticosteroids, e.g., prednisone, methylprednisolone, dexamethasone, ortriamcinalone acetinide, or noncorticosteroid anti-inflammatorycompounds, such as ibuprofen or flubiproben. Similarly, vitamins andminerals, e.g., zinc, and micronutrients can be co-administered. Inaddition, inhibitors of the protein tyrosine kinase pathway, whichinclude natural protein tyrosine kinase inhibitors like quercetin,lavendustin A, erbstatin and herbimycin A, and synthetic proteintyrosine kinase inhibitors like tyrphostins (e.g., AG490, AG17, AG213(RG50864), AG18, AG82, AG494, AG825, AG879, AG1112, AG1296, AG1478,AG126, RG13022, RG14620 and AG555), dihydroxy- and dimethoxybenzylidenemalononitrile, analogs of lavendustin A (e.g., AG814 and AG957),quinazolines (e.g., AG1478), 4,5-dianilinophthalimides, andthiazolidinediones, can be co-administered with genistein or an analog,prodrug or pharmaceutically acceptable salt thereof (see Levitzki etal., Science 267: 1782-1788 (1995); and Cunningham et al., Anti-CancerDrug Design 7: 365-384 (1992)). In this regard, potentially usefulderivatives of genistein include those set forth in Mazurek et al., U.S.Pat. No. 5,637,703. Selenoindoles (2-thioindoles) and related disulfideselenides, such as those described in Dobrusin et al., U.S. Pat. No.5,464,961, are useful protein tyrosine kinase inhibitors. Neutralizingproteins to growth factors, such as a monoclonal antibody that isspecific for a given growth factor, e.g., VEGF (for an example, seeAiello et al., PNAS USA 92: 10457-10461 (1995)), or phosphotyrosine(Dhar et al., Mol. Pharmacol. 37: 519-525 (1990)), can beco-administered. Other various compounds that can be co-administeredinclude inhibitors of protein kinase C (see, e.g., U.S. Pat. Nos.5,719,175 and 5,710,145), cytokine modulators, an endothelialcell-specific inhibitor of proliferation, e.g., thrombospondins, anendothelial cell-specific inhibitory growth factor, e.g., TNFα, ananti-proliferative peptide, e.g., SPARC and prolferin-like peptides, aglutamate receptor antagonist, aminoguanidine, an angiotensin-convertingenzyme inhibitor, e.g., angiotensin II, calcium channel blockers,γ-tectorigenin, ST638, somatostatin analogues, e.g., SMS 201-995,monosialoganglioside GM1, ticlopidine, neurotrophic growth factors,methyl-2,5-dihydroxycinnamate, an angiogenesis inhibitor, e.g.,recombinant EPO, a sulphonylurea oral hypoglycemic agent, e.g.,gliclazide (non-insulin-dependent diabetes), ST638 (Asahi et al., FEBSLetter 309: 10-14 (1992)), thalidomide, nicardipine hydrochloride,aspirin, piceatannol, staurosporine, adriamycin, epiderstatin,(+)-aeroplysinin-1, phenazocine, halomethyl ketones, anti-lipidemicagents, e.g., etofibrate, chlorpromazine, spinghosines and retinoic acidand analogs thereof (Burke et al., Drugs of the Future 17 (2): 119-131(1992); and Tomlinson et al., Pharmac. Ther. 54: 151-194 (1992)).

V. Diagnostic Applications

The disclosure further relates to diagnosing or prognosticating the riskof developing galactosemia in a subject by measuring one or morebiomarkers associated with galactosemia. In one embodiment, thebiomarker associated with galactosemia is increased galactitol levels ina biological sample obtained from a subject. Diagnosis may be performed,e.g., by detecting elevated levels of sugar metabolites, e.g.,metabolites of galactose (e.g., galactitol) and/or glucose (e.g.,sorbitol) in the biological sample, e.g., aqueous or vitreous humor ofthe eye, blood tissue, cerebrospinal fluid, urine, etc.

Tables 1 and 2 show concentrations of galactose and metabolites thereofin plasma (or whole blood), erythrocyte, and/or urine samples ofsubjects with classic galactosemia (GALT deficiency) or severe GALKdeficiency.

The disclosure further relates to methods for combined diagnosis andintervention of galactosemia, wherein, diagnosis of galactosemia iscarried out as described previously via detection of one or morebiomarkers in a sample obtained from the subject. Based on the resultsof the diagnosis, if the subject is determined to have or deemed to beat risk of developing galactosemia, then a composition comprising analdose reductase inhibitor (ARI) is administered to the subject.Preferably, the ARI comprises a compound of the instant disclosure or acomposition comprising the compound of the instant disclosure.

In certain embodiments, the present disclosure provides a method fortreating galactosemia, comprising diagnosing a subject for galactosemiaby detecting elevated plasma galactitol concentration (e.g., >10 μMgalactitol) and/or elevated urinary galactitol levels (e.g., >100 mmolgalactitol/mol of creatine); and administering to the galactosemicsubject in need thereof, an therapeutically effective amount of acomposition that inhibits aldose reductase activity. In anotherembodiment, the diagnosis step may further comprise a genetic test,e.g., detecting a mutation in one or more of the enzymes involved inLeloir pathway (e.g., GALT, GALK, GALE, etc.). In yet anotherembodiment, the diagnosis step may additionally comprise conducting anenzymatic assay, e.g., an assay for GALT, GALK, and/or GALE activityusing detectable substrates, the products of which may be detected usingroutine methods, e.g., HPLC or mass spectrometry (Ko et al., ClinicalChemistry 56:5 764-771, 2010).

The present disclosure further provides for the use of the compounds ofFormula I-VI, or a pharmaceutically acceptable salt, hydrate, solvate,or prodrug thereof, in a method of treating a disease state, and/orcondition caused by or related to galactosemia. In another embodiment,the disclosure relates to use of the compounds of Formula I-VI, or apharmaceutically acceptable salt, hydrate, solvate, or prodrug thereof,in a method of treating a disease state, and/or condition caused by orrelated to galactosemia, comprising the steps of: (a) identifying asubject in need of such treatment; (b) providing a compound of FormulaI-VI, or a pharmaceutically acceptable salt, hydrate, solvate, prodrugthereof; and (c) administering said compound of Formula I-VI in atherapeutically effective amount to treat, suppress and/or prevent thedisease state or condition in a subject in need of such treatment.

In another embodiment, the disclosure relates to use of the compounds ofFormula I-VI, or a pharmaceutically acceptable salt, hydrate, solvate,or prodrug thereof, in a method of treating a disease state, and/orcondition caused by or related to galactosemia, comprising the steps of:(a) identifying a subject in need of such treatment; (ii) providing acomposition comprising a compound of Formula I-VI, or a pharmaceuticallyacceptable salt, hydrate, solvate, prodrug or tautomer thereof; and(iii) administering said composition in a therapeutically effectiveamount to treat, suppress and/or prevent the disease state or conditionin a subject in need of such treatment.

In the aforementioned embodiments, the compound or composition ispreferably used orally.

EXAMPLES

The structures, materials, compositions, and methods described hereinare intended to be representative examples of the disclosure, and itwill be understood that the scope of the disclosure is not limited bythe scope of the examples. Those skilled in the art will recognize thatthe disclosure may be practiced with variations on the disclosedstructures, materials, compositions and methods, and such variations areregarded as within the ambit of the disclosure.

Rats, with impaired GALT activity due to genetic modification (GALTnull), were used as a model of galactosemia. This rat model mirrorshuman classic galactosemia in some important ways. The rats developphysical characteristics including cataracts follow exposure togalactose, growth abnormalities, and neurological/cognitiveabnormalities, which mirror abnormalities in human patients and can bequantified. The rats also have biochemical characteristics that mirrorhuman disease including elevated levels of galactose and galactosemetabolites, including galactitol and Gal1), in blood and tissues.

The rats will be fed a diet containing one or more aldose reductaseinhibitors (ARIs), and the effect of AR inhibition will be assayed atthe tissue level and also at the in vivo level. For instance, galactitollevels in the eye of GALT-deficient rats may be measured pre- andpost-treatment with the ARIs disclosed herein. Alternately oradditionally, the effect of ARIs in reducing the frequency and severityof galactosemia and/or improving the outcome of the disease (e.g.,improved visual, motor or memory skills) will be measured using routinemethods.

Example 1

A study was conducted to test the effects of aldose reductase inhibitors(ARI) (Compound A or Compound B) in the rat model of classicgalactosemia (GALT-null rats). The effects of aldose reductase inhibitortreatment on key aspects of galactosemia including growth, formation ofcataracts, and metabolite levels (galactose & galactitol) in liver andbrain and circulation of GALT null rats exposed to maternal milk wasanalyzed.

Methodology

Genetic Model:

Rats were generated from heterozygote crosses (heterozygous M3 GALT nullstrain representing classic galactosemia). Wild-type (WT, +/+) andheterozygous rats (+/M3) express normal levels of GALT, whereas M3homozygotes (M3/M3) do not express GALT at detectable levels, and showaberrantly high levels of galactose and galactitol in liver and brain.

Application of Drug and Placebo:

The vehicle used to administer the drug to newborn pups was Gerber GoodStart Birth-12 Months soy formula prepared according to themanufacturer's instructions (157.5 mg powder added to 1 ml deionizedwater and mixed well before use). Liquid formula was prepared fresh frompowder each day and stored at 4° C. until use. Liquid formula alone (nodrug powder added) served as a placebo control.

Aldose reductase inhibitor (Compound A or Compound B), suspended inGerber formula, was administered orally at about 12-hour intervals (BID)at 1 mg inhibitor/gram pup weight (=1000 mg/kg) for each dose. Beforeuse, drug was stored at −20° C. in a bottle or tubes wrapped in aluminumfoil. Just before each feeding an aliquot of drug was re-suspended informula, mixed well, and pipetted into individual tubes to be fed to thepups (volume calculated per pup weight measured that morning). Allplacebo and drug tubes of formula were warmed to 37° C. immediatelybefore feeding.

Placebo and drug were fed to pups by hand using a syringe and tubing.Pups receiving drug also were fed a small additional volume of Gerberformula that had been used to wash the tube and syringe immediatelyafter the drug feeding. To motivate eating, pups were removed from theirmother (to prevent nursing) and maintained in nests in a humidifiedincubator for about 2 hours at 35-37° C. prior to each feeding. Separatesyringes were used for placebo and drug. Pups were wrapped in fleeceduring feeding, which lasted about 2-5 minutes each.

Tracking Growth:

Growth was tracked (in grams) by weighing each pup every day.

Tracking/Quantifying Cataracts:

In the first part of the study, cataracts were scored visually by ablinded rater on a 3 point scale, with zero being no cataracts present(absent), 1 being mild, 2 being moderate and 3 being severe cataractspresent. In the second part of the study, eyes were dissected aftereuthanization, photographed via digital camera, and cataracts werequantified via software

Determining Genotypes:

Pup GALT genotypes (M3/M3 versus M3/+ versus+/+) were determined byTransnetyx using DNA isolated from tail snips collected from all pups atbetween 5-8 days after birth. Genotypes were corroborated inrepresentative pups by GALT enzyme activity measured in liver samplesharvested from pups after euthanasia. In all samples tested, the GALTactivity observed was consistent with the GALT genotype.

Euthanizing Pups:

Pups were euthanized by CO₂ inhalation according to standard procedures.

Enzyme Assays:

Galactose-l-P uridylyltransferase (GALT) and galactokinase (GALK) assayswere performed as described previously (Sanders et al., Dis Model Mech.,3(9-10):628-38, 2010) using lysates prepared from frozen samples ofliver. GALK assays were performed as a control for integrity of thesamples. Lysates were prepared by homogenizing small pieces (10-50 mg)of liver in 100 μl of lysis buffer consisting of one complete miniprotease inhibitor cocktail tablet, EDTA-free (Roche, REF 04 693 159001) dissolved in 10 ml of 100 mM glycine, pH 8.7. The lysates werecentrifuged at 16,110×g for 5 mins at 4° C., and the resultingsupernatant was passed over a MICRO BIO-SPIN P-6 chromatography column(Bio-Rad, Inc.) to remove small molecules. Protein concentrations weredetermined for each sample using the BIO-RAD DC protein assay with BSAas the standard. GALT and GALK assays were run using 4 μg of totalprotein per reaction. Substrates and products were quantified by HPLC asdescribed previously (Ross, 2004).

Metabolites:

Lysates for metabolite analysis were prepared as follows: 50-100 mgpieces of previously frozen liver or brain were homogenized by grindingfor 30 seconds using a Teflon micropestle and handheld micropestle motor(Kimble Chase Life Science and Research Products LLC) in 125 μl ice-coldHPLC-grade water. Metabolites were separated and quantified by HPLC(See, e.g., Daenzer, et al. Dis. Model Mech. 2016, 9(11):1375-1382)).Galactitol, inositol, and glucose were quantified using the same HPLCconditions described to quantify galactose by (Daenzer, 2016).Metabolite levels were normalized to the total area of peaks detected bythe relevant column and elution run for that sample, minus the peaksthat most distinguished homozygous M3/M3 samples from controls.Specifically, metabolites separated on the MA1 column (galactitol,inositol, galactose and glucose) were normalized to total peak areaminus galactose and galactitol, and metabolites separated on the PA10column (galactose-1P) were normalized to total peak area minus galactoseand galactose-1P.

Results

Observations from the in-Life Period:

Though formula with drug was slightly “thicker” in consistency thanformula alone, pups consumed both without apparent objection.

Growth:

Pups were weighed each morning and mass was recorded the in grams. Themasses of pups that were still gaining weight are presented in FIG. 1.As illustrated, weights of homozygous GALT null pups tended to lagbehind their wild-type and heterozygous GALT+ littermates, but thedifference was subtle. Other studies have demonstrated that the lagbecomes more pronounced and statistically significant after the 3rd weekof life.

The data presented in FIG. 1 indicate that drug treatment can reduce orprevent the growth lag in homozygotes.

Cataracts:

Cataracts are the most obvious and visible phenotype associated withGALT-null status in the rat model. The rats open their eyes at day 14 oflife with bilateral cataracts present. Of note, infants with classicgalactosemia exposed to dietary galactose (e.g., breast milk) alsodevelop bilateral cataracts. In the GALT null rat model, absentintervention, cataracts are seen in all M3/M3 homozygous pups but not inany M3/+ or +/+ pups. In an initial study, cataracts were qualitativelyassessed in GALT null rats that were treated with Compound A or placeboat day nine of life. The qualitative assessment was on a scale of 0-3with 0 indicating cataracts were absent and 3 indicating severecataracts. As shown in FIG. 2A GALT null rats that were treated withplacebo developed sever cataracts by day nine of live. In contrast GALTnull rats treated with Compound A had no cataracts. A follow-on studywas performed in which rats were treated with Compound A at 1,000 mg/kgBID or 250 mg/kg BID and eyes were digitally photographed and cataractswere quantified. In both studies, Compound A reduced cataracts.

Additional studies were conducted using Compound B, and cataracts wereassessed at day 22 of life. Qualitative assessment on the 0-3 scale,show that in this study GALT null rats treated with placebo developedcataracts with average severity of 1.5, but wild type rats and GALT nullrats treated with Compound B did not have cataracts (FIG. 2D). Digitalquantitative analysis produced the same results, with GALT null ratstreated with Compound B having the same score as wild type rats, butGALT null rats treating with placebo having a higher score indicative ofcataracts. (FIG. 2B)

Since GALT null rats have cataracts when they open their eyes on day 14of life, it is possible that treatment of new born rats with aldosereductase inhibitors prevents the formation of cataracts in thepost-natal period and/or reduces cataracts that formed in utero. Afurther study using Compound B, provided evidence that aldose reductaseinhibitors can reduce cataracts that are already formed. In this study,cataracts were assessed at days 10 and 22 of life. As shown in FIG. 2Cand FIG. 2D, GALT null rats treated with placebo had cataracts at day 10and at day 22. However, GALT null rats treated with Compound B hadcataracts at day 10, but cataracts were not present at day 22. The datademonstrate that treatment with aldose reductase inhibitors can reduceand resolve cataracts.

Metabolites:

Galactose and galactitol metabolites were resolved and quantified viaHPLC in samples of both liver and brain from euthanized pups. Treatmentwith Compound A reduced liver galactitol levels by 87% compared toplacebo in GALT null rats at day 9 and by 57% at day 15-18. Treatmentwith Compound A reduced brain galactitol levels by 40% compared toplacebo in GALT null rats at day 9 and by 57% at day 15-18. Additionalstudies were conducted in rats treating using Compound B, and galactoseand galactitol levels were measured at day 10 of life. The results ofthis study showed that GALT null rats had elevated levels of galactitolin the liver, brain and plasma in comparison to wild type rats.Treatment with Compound B reduced galactitol levels in GALT null rats tonormal or near normal levels. (FIG. 3A). The GALT null rats also hadelevated galactose and Gal1P levels, relative to wild type rats.Treatment with Compound B did not further increase the galactose orGal1P levels in the GALT null rats. (FIG. 3B, and FIG. 3C). The datademonstrate that aldose reductase inhibitors can reduce and normalizegalactitol levels in affected animals, but does not further elevategalactose and Gal1P levels.

Conclusions and Discussion

This study examined the effects of Aldose Reductase inhibitor exposure(Compound A or Compound B) on growth, cataract formation and galactitolaccumulation in GALT-null rat pups. As expected, milk-exposed GALT nullanimals accumulated dramatically elevated galactose and galactitol inboth liver and brain relative to GALT+ heterozygotes or wild-typeanimals. Treatment with aldose reductase inhibitors significantlylowered galactitol in brain, liver and blood (plasma). Treatment withaldose reductase inhibitor also had dramatic effects on cataracts, anddemonstrate that aldose reductase inhibitors can reduce existingcataract to the point where cataract in no longer present. These datademonstrate that aldose reductase inhibitors can be administered toeffectively treat galactosemia.

Example 2

In this study longer-term cognitive and neurological deficienciesassociated with galactosemia will be studied in GALT null rats andnormal control rats that are treated with placebo or with aldosereductase inhibitor. The aldose reductase inhibitors will beadministered substantially as described in Example 1, and rats will beevaluated for central nervous system outcomes using rotarod testing, toassess balance, motor control and learning, as well as using novelobject recognition testing, to assess cognition and memory. GALT nullrats show altered responses in these tests in comparison to wild typerats. The data will show that treatment with aldose reductase inhibitordecreased cognitive and neurological deficiencies of GALT null rats, andthat some or all responses of GALT null rats were normalized to theresponses observed in wild type rats.

Example 3

A newborn child is diagnosed with classical galactosemia by neonataltesting and presents with elevated blood galactose and galactitollevels. The child is immediately place on a galactose and lactoserestricted diet. Therapy with an aldose reductase inhibitor (such asCompound A or Compound B) is initiated at a dose selected by theclinician to normalize blood galactose and/or galactitol levels.Treatment results in reduction and eventual normalization of bloodgalactitol levels. The child continues therapy indefinitely and periodicchecks confirm that blood galactitol levels remain normal. Dosing isadjusted as needed to maintain normal blood galactitol levels. The childdoes not exhibit growth delay, delayed speech, impaired learning, motorataxia or presenile cataracts as she ages.

Example 4

An adult patient with galactosemia presents with motor ataxia,spasticity and poor balance. Therapy with an aldose reductase inhibitor(such as Compound A or Compound B) is initiated at a dose selected bythe clinician to normalize blood galactose and/or galactitol levels.Treatment results in reduction and eventual normalization of bloodgalactitol levels. As galactitol levels normalize, the patient exhibitsdecreased motor ataxia and spasticity, and improved balance. Dosing isadjusted as needed to maintain normal blood galactitol levels, andimprovements in the patient's motor control and balance.

Unless otherwise defined, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this disclosure belongs.

Although methods and materials similar or equivalent to those describedherein can be used in the practice or testing of the present disclosure,suitable methods and materials are described in the foregoingparagraphs. In addition, the materials, methods, and examples areillustrative only and not intended to be limiting. All United Statespatents and published or unpublished United States patent applicationscited herein are incorporated by reference. All published foreignpatents and patent applications cited herein are hereby incorporated byreference. All published references, documents, manuscripts, scientificliterature cited herein are hereby incorporated by reference. Allidentifier and accession numbers pertaining to scientific databasesreferenced herein (e.g., PUBMED, NCBI, GENBANK, EBI) are herebyincorporated by reference.

1. A method of treating galactosemia or preventing complicationsassociated with galactosemia, comprising administering a therapeuticallyeffective amount of an aldose reductase inhibitor to a subject in needthereof.
 2. A method of reducing the amount or level of galactitol in asubject with galactosemia, comprising administering a therapeuticallyeffective amount of an aldose reductase inhibitor to the subject.
 3. Amethod for treating cataracts, comprising administering atherapeutically effective amount of an aldose reductase inhibitor to asubject in need thereof.
 4. The method of claim 3, where the subject inneed thereof has galactosemia.
 5. A method for treating or preventingcognitive or neurological deficiency associated with galactosemia,comprising administering a therapeutically effective amount of an aldosereductase inhibitor to a subject with galactosemia.
 6. The method ofclaim 5, wherein the cognitive or neurological deficiency associatedwith galactosemia is speech dysfunction.
 7. The method of claim 5,wherein the cognitive or neurological deficiency associated withgalactosemia is motor ataxia.
 8. The method of claim 5, wherein thecognitive or neurological deficiency associated with galactosemia iscognitive dysfunction.
 9. The method of claim 5, wherein the cognitiveor neurological deficiency associated with galactosemia is pseudomotorcerebrii.
 10. The method of claim 5, wherein the cognitive orneurological deficiency associated with galactosemia is seizure.
 11. Themethod of claim 1, wherein the aldose reductase inhibitor is a compoundof any one of Formulas I-III or salt thereof.
 12. The method of claim 1,wherein the aldose reductase inhibitor is a zopolrestat or salt thereof,or epalrestat or salt thereof.
 13. The method of claim 1, wherein thealdose reductase inhibitor is a compound of Formula (II) or saltthereof.
 14. The method of claim 13, wherein the aldose reductaseinhibitor is selected from the following or salts thereof


15. The method of claim 1, wherein the aldose reductase inhibitor is acompound of Formula III.
 16. The method of claim 15, wherein the aldosereductase inhibitor is selected from the following or salts thereof


17. The method of claim 1, wherein the subject is a human.
 18. Themethod of claim 1, wherein the galactosemia is manifested in the subjectas increased alditol levels in blood, urine or intraocular fluid. 19.The method of claim 18, wherein the alditol is galactitol, myoinositolor sorbitol.
 20. The method of claim 1, wherein the galactosemia ismanifested in the subject as increased liver cirrhosis, retinaldisorder, macular edema, eye cataract, ovarian dysfunction, muscle ornerve dysfunction, retinopathy, neuropathy, impaired neural conductionor mental retardation.
 21. The method of claim 1, wherein thegalactosemia is Type I Galactosemia (GALT deficiency).
 22. The method ofclaim 1, wherein the galactosemia is Type II Galactosemia (GALKdeficiency).
 23. The method of claim 1, wherein the galactosemia is TypeIII Galactosemia (GALE deficiency).
 24. The method of claim 1, whereinthe aldose reductase inhibitor is Compound A or a salt thereof.
 25. Themethod of claim 1, wherein the aldose reductase inhibitor is Compound Bor a salt thereof.